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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005813
Report Date: 07/26/2022
Date Signed: 07/26/2022 03:18:30 PM

Document Has Been Signed on 07/26/2022 03:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:A MISSION FOR MICHAELFACILITY NUMBER:
306005813
ADMINISTRATOR:NARAINE, KIMBERLYFACILITY TYPE:
772
ADDRESS:26972 VIA BANDERASTELEPHONE:
(949) 313-7444
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY: 6CENSUS: 5DATE:
07/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Dan RobinsonTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced to conduct the required annual inspection (mitigation). LPA was screened for symptoms of Covid-19 and granted entry. LPA met with Program Director Dan Robinson. LPA explained the reason for the visit. LPA and Program Director toured the facility. Facility is a one story house with 3 bedrooms, 2 bathrooms, living room, dining room, kitchen, staff room and a 2 car garage. LPA observed a 2 day perishable and a 7 day perishable food supply on hand in the kitchen. The kitchen is clean and organized. LPA observed the fireplace in the dining room is screened. LPA observed the PUB 475 poster posted next to the entrance. LPA observed all of the client bedrooms had the required furnishings. The hot water measured 114.4 degrees Fahrenheit. LPA observed both bathrooms were clean and operational. No bodies of water observed in the backyard. There is a covered patio with chairs in the patio and a ping pong table. The exit gate leading to the front of the house is operational. LPA inspected the First Aid Kit. The First Aid Kit has all the required elements. The smoke detectors/carbon monoxide detectors tested operational. No obstacles or hazards observed inside or outside of the facility. No deficiencies observed. No deficiencies are being cited as a result of this visit.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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